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Y UNIFI D PROGRAM CONSOLIDATED FCW r\ <br /> 1111"k'r,' TANKS <br /> UNDERGROUND STORAGE TANKS FACILITY <br /> (one page per site) <br /> TYPE OF ACTION r 1.NEW SITE PERMIT F 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Specify change- r 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) <br /> F 2.NEW OPERATOR X 4.AMENDED PERMIT local use only); r 8.TANK REMOVED 400 <br /> r 6.TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# 1 <br /> Country Club Shell, Craig Furgison/Steve Griffen F'A Doo&1131 <br /> 2575 Country Club Blvd, Stockton CA 95204 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE r 4. LOCAL AGENCY/DISTRICT- <br /> Plymouth X 1. CORPORATION r 5. COUNTY AGENCY' <br /> F 2. INDIVIDUAL r 6. STATE AGENCY' <br /> BUSINESS TYPE X 1.GAS STATION F 3.FARM r 5.COMMERCIAL r 3. PARTNERSHIP <br /> r 2.DISTRIBUTOR F 4.PROCESSOR IF 6.OTHER r 7. FEDERAL AGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is a public agency:name of supervisor of <br /> REMAINING AT SITE trustlands7 division,section or office which operates the UST. <br /> (This is the contact person for the tank records.) <br /> 404 3 F Yes X No 405 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME -har' PHONE 408 <br /> Shell Oil Products US C/O Bruce T. Marubashi, H,SBE Analyst 1925-766-3498 <br /> MAILING OR STREET ADDRESS 409 <br /> P.O. BOX 8509 <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> SAN JOSE CA 95155 <br /> PROPERTY OWNER TYPE F 2. INDIVIDUAL r 4. LOCAL AGENCY I DISTRICT r 6. STATE AGENCY 413 <br /> X 1. CORPORATION r 3. PARTNERSHIP F 5. COUNTY AGENCY r 7. FEDERAL AGENCY <br /> IIL TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> SAME AS II <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> TANK OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 420 <br /> I 1 CORPORATION r 3. PARTNERSHIP F 5. COUNTY AGENCY r 7. FEDERAL AGENCY <br /> IV 5nARI)nEFQIIAI17AIIC)blllSlSlnRAGF:F:r-;:Ar-COIININIIMR;:R <br /> TY(TK)HQ 4 4 0 3191 0 2161 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) r 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> r 2. GUARANTEE r 5. LETTER OF CREDIT r 8. STATE FUND 8 CFO LETTER r 99. OTHER: <br /> X 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND 8 CD 422 <br /> Check one box to indicate which address should be used for legal notifications and mailing. X 1. FACILITY r 2. PROPERTY OWNER r 3. TANK OWNER 423 <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. <br /> VII A12121 ICANI SIGNAII IRE <br /> Certification: i certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNAT E OF APPLICAN> DATE 424 PHONE <br /> 4/5/02 925-766-3498 425 <br /> IE OF APPLICANT(print) TITLE OF APPLICANT 427 <br /> BRUCE T. MARUBASHI for Shell Oil Products US 426 H,SBE Analyst <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(Forlocal use only) 429 <br /> JPCF(1/99 revised) 5 Formerly SWRCB Form A <br />